scenario number one to under scenario number two, the cost to treat oca veterans in 2020 is more than 50% higher than in scenario one, 8.4 billion. costs over 10 years would total 55 billion. almost two-thirds of the cost difference is due to the faster growth and expenditures per enrollee. thank you very much. and happy to answer any questions. >> thank you very much. thank you again to all of your testimony today. it's really appreciated. ms. nicely, i want to start with you. when i first met you up in bethesda i was really disconcerted when you told me that you have been waiting forever for a husbands joined disability evaluation process. you had to wait almost 70 days for approval of a simple narrative summary. i went and checked, and what i understand is a summary only needs to state the obvious, that your husband was indeed missing two legs and to arms.

and essentially sat on some his desk for more than two months. that is just really unacceptable. and my apologies to you and your family on behalf of of everyone for that. but i wanted you, as you shared with me, to talk to me a little bit about what you are going through for the 70 days while this country essentially bureaucratically put you on hold. >> i think todd's therapy, it's very important, but he got to a point in his therapy where he was able to do more stuff, more independently, which didn't require his therapist to be there. i guess during the whole time. so, it's kind of like a requirement, i don't know if it's just marine corps procedure or whatever, that they go into therapy. and if todd was not being taught new things or he was just getting redundant comment doing the same things over and over

again, so he had pretty much accomplished much of what he has wanted to within that timeframe, which meant he was taking up more space that other people could have been utilizing the therapist, and so, i guess why pay for his therapy, or wide you could be paying it for somebody else. so just a waste of time i guess. >> what were you spending your time doing? >> support taking him, taking todd back and forth to therapy, and just helping him with staying in moving. >> you talk to me about corners of care, that their comments are changing every two months and union more than they did, and they left and then you are training the coordinators of care. can you share with us about that? >> i don't want to say that all of them are at fault due to the situation, because of the way it is. but the way that the military

side has the liaisons coming in and out is very frustrating, because they are not mos specific that they are not trained in the jobs to get done that are being asked of them. so they come near without the knowledge of what they are expected to do. and take the time while they're here to learn what they're doing. and by the time that they have adjusted, and maybe have absorbed some of the company is time for them to leave again and new individuals come into are still not mos specific. so that doesn't help us. what they are here for, the frustration helping the stress off and able to do the things that are necessary, and instead, me personally had to look for outside assistance from whether it was other families support, or my case manager or, but was

not assisted on the military side of things. that also doesn't aid, for me in the beginning of family process it's really hard to open up to people and trust individuals. so to be able to get a connection with somebody and have somebody therefore that short period of time, and then transition at and somebody else new is not allowing us to have that connection or allow us to want to open up to them. because we are like okay, if we come to you, what are you going to do for me because i know more than you do. so it's extremely frustrating. i know they have been working on it but it is still frustrating. >> you are a tremendous advocate for your husband, and i am extremely impressed with todd's, capable of doing, and i know you are proud of that as well. i also know that he needs you at his side, and you either every single minute doing that. you met many people through this process. what does somebody do doesn't doesn't have a wife or a

caregiver? >> i think -- oh, boy. that's hard because you do see it in some cases, the family support is maybe not there, or maybe not there for the right reasons, or -- i think because the lack of, i don't want is a lack of knowledge, but their ability to assist in a lot of ways and lack of compassion when it comes to a lot of these guys, their next choice would be to reach out to somebody, i don't know, that, whether through military side of things or for the hospital, the hospital staff is wonderful. i guess there's not really a way to say -- >> maybe if you can share with this committee, share with what you're day is like. >> recently a lot easier. it's normal because todd has strived to become very independent with his prosthetic. without his prosthetics i would

be doing the work for two people every day. and with his prosthetics, and because of his knowledge and what he's been able to absorb to his therapist and his daily work and putting into therapy, i basically just observe and watch, and if he needs assistance, then i assist him if he asks, of course. >> thank you. and thank you for your courage in being here again. mr. reich off, our governments ability to fulfill the sacred responsibilities come into question by the ongoing debt crisis that is in front of us today. if the debt limit is not raised, some have speculated government will not have enough money to provide veterans benefits checks, as you can imagine, and i'm sure you know this has caused an acquittal amount of anxiety among our veterans, and, of course, their families. ..

>> they're scared. some of these folks who are 100% disabled have gotten no additional informing, and -- informing, people are more and more concerned by the day. and i think what they want, they understand generally where the debate is. they don't understand the specifics of how it will impact them. no one has been able to project how they should plan for the next 60 days. >> i assume there's a lot of frustration. >> incredible frustration. just devastating disappointment.

and it's become demoralizing. not even more folks just stateside, but overseas. there's a guy on a checkpoint in afghanistan who doesn't know for certain what's going to happen to him and his family in 30 days. that is ridiculous. and it's outrageous, and our members are beyond upset. and so i would ask this committee, if you can help us get certainty, we've got e-mails standing by. i can send it out to them within an hour and let them know what's going on, but we need clarity and guidance from you all in this town about what to tell them, and we don't know want to tell them that. >> thank you very much. senator brown? >> thank you very much. chris, i was concerned a little bit, you mentioned in be your initial testimony about you have to go and get recertified on a regular basis to be in your position as a home care -- >> yes, sir. >> can you tell me a little bit about that? like, what they've told you, what's the process, how long

does it take, why have they told you that you need to do it? >> in the beginning, from my understanding, it has, it requires a doctor's approval, so they -- from be, if, like a reevaluation of the military service members' health and how they're getting better on a day-to-day basis. so the use or the need of a medical attendant, i believe, is why they make us reapply for it. and it takes quite a long time. um, in the beginning very, i don't know, months almost. i know there was a waiting list for nonmedical attendant assistants. and i, from my understanding, they're working on it to improve that, and it has improved in speed wise. but going about how to get approved and the stipulations

and what a better understanding of it is needed, i would have to say. >> so how long does it actually, how long does your certification actually last? >> i think the longest that you can request, um, a nonmedical attendant is six months. >> so how long, how many times have you had to recertify? >> um, i've actually only had to do it once for myself due to, i guess, the stipulations or the requirements of the law that due to i am transferred by record books to where my husband is, that i no longer rate it. but i know from other family members and other individuals that have gone through it had to reapply many times. i don't know if that's due to the process or the loss of paperwork or, um -- >> so thank you for that. i'm wondering, how long has todd

been part of the ides? >> he has -- what do you mean by that? >> well, he's been going through, i know, the expedited disability system. when did, in listening to your testimony, you said it was very frustrating, and there were breakdowns. and i was sensing you didn't want to blame anybody because, you know, you're thankful, obviously, for the things that you have. but on the other hand, you're upset at the fact that no one seems to be coming and saying, hey, listen, this is what you have, this is where you get it, this is where you go and this is how much you're going to get of the assistance. has anyone ever done that and actually sat down and laid it all out to you on a piece of paper so you can almost actually have a flow chart? >> before senator murray spoke gave us more understanding of how the med board process went and what was to be expected of it except that it was going to

take a very long time. that was what we were informed of. >> so how long is it from point a to senator murray getting involved? >> we started todd's med board i want to say january time frame because they said that there was a possibility that it would take quite a long time. so by the time todd was ready and therapy was, you know, therapy was completed and he was ready to leave the hospital that it should be completed. >> so you mentioned just the summary took seven months, it was on somebody's desk -- >> 70 days. >> i'm sorry, 70 days. were you given any reason for that? >> um, when we officially thought it was just sitting on someone's desk, i believe that's what we were informed of, that it was just sitting and waiting. >> well, certainly not acceptable. and what type of -- are you recognized in any additional

hassles or problems, things moving along more expeditiously now? >> oh, yes. um, she, as in][[a senator mur, really put -- kicked 'em in the butt, and there -- [laughter] we have not had any issues since. >> well, that's great. you know, it's interesting because according to original estimates there's 42,000. does it take a senator to kick people's butts to get help for those other, you know, soldiers that are -- and family members -- that are having similar problems? you have a husband that's, obviously, extremely injured, and, um, you know, for him to have to go through that stuff and you as well i just find once again, you know, getting back to the fact that the va is not here. and maybe i would suggest senator -- i'm just sitting in as a ranking member today, but

senator byrd's consideration, also, that we find out, like, why. >> and senator brown, i appreciate that. i will say that the military was responsible at this point, and secretary lynn is personally involved. >> great, thank you. my time's up, and there's other members. i'll come back. >> thank you very much. senator tester? >> yeah, thank you, madam chair. and thank you all for your testimony. crystal, thank you especially. you talked about your gratitude for chairwoman murray, and we are all grateful for chairwoman murray, but the fact is the gratitude goes the other way. we thank you for what you do. we thank you for the sacrifices that your husband and you have given this country. we can't repay you. that's just the way it is. there's nothing we can do to repay what you've sacrificed. and i think the va is probably listening to this hearing, and i think constructive criticism you've given is very positive. the questions about the ids process, the section leader, the mna recertification were already

asked, i'm not going to ask them again. i think you did a fibrojob. obviously, there needs to be more education done, there needs to be some streamlining because, quite honestly, with the number of disabled vets out there the action of a senator, there's no way we can do it all. so the va has to step up in a bigger way, and i think they're hearing that message through c-span or whatever means it might be today of -- today. paul, i'd like to echo your testimony. i think the lifetime costs are huge, but i think intervention in the beginning can save money and make quality of life better for our veterans. um, seems like a lot of the problems stem from access, a lot of problems stem from education. it's particularly different, difficult in rural america. we've tried to do some things, have tried to enhance mileage, tried to get more clinics out there, tried to get telemedicine

going, um, more employment counselors in rural america. the challenges are many. um, this is not a fair question. um, but i'm going to ask it anyway. um, if you're going to look from a rural america perspective, the challenges that are out there, we've made some improvements. is there more we need to be doing, and what areas would you invest in if you were sitting in this chair? >> yes, sir. there's a lot of room for improvement. and that's what we hear consistently from our members. one thing that i think is important for this committee and for this entire town to really wrap their heads around is right now only 53% of our veterans are enrolled in va health care. only half. so we've got to think more creatively. the country thinks the va is the one stop, the only solution, the silver bullet that is going to solve all the problem of this generation. and the va is improving. obviously, we're disappointed they're not here, they have a

long way to go, but we've also got to think more creatively. we've got to enroll the private sector, the faith-based community, the people who are in those rural communities. because the va has not innovated as a nationwide model. it's still catching up from 30 years ago in every way, shape and form. so what we've seen as successful is leveraging technology especially, and that's how you can get to those folks where they have, you know, decent access to the internet. but that does give you a tremendous opportunity for innovation and for impact. you're not going to be able to bring everybody 400 miles to the nearest facility. so we've got to think creatively and invest in the community-based solutions that are working. find those pilots and take them to scale. because that's where we see in the field the most entrepreneurial attitude. it's that church group or vfw hall. we haven't seen a lot of innovation that's really been encouraged and taken to scale

outside of the va. so that is kind of, i think, a big bite of the apple that we have to start taking on. the president's got to talk about more than the va when we talk about veterans. >> okay. thank you. i want to talk about local contracting. um, and i don't -- whoever, i guess initially it would be for ms. st. james, but whoever would like to answer this. um, it is a huge issue in my state. the inability for the va to recruit and retain doctors and surgeons is a big, big, big issue. um, we haven't had a full-time orthopedic surgeon in montana for several months. the va's trying to recruit one, they can't get 'em. and now we've got veterans who have to travel out of state, um, out of pocket care, quality of life goes down, there's 400 veterans on a wait list now that's approaching two years for

orthopedic surgeries. it is completely unacceptable, and i know montana's not the only state in this boat. um, i don't think it's cost effective to ship somebody, um, miles and miles, hundreds of miles away from their home for surgery when they could be contracted locally in areas where we can't get docs in the va. um, can you tell me if this makes sense to you, to locally contract if you can't get a doctor that's a specialist? and if it's not, if it's not you, mrs. st. james, somebody else can answer the question. but it appears to me that this could help solve a problem where we have need, and we can't fill the positions. it just seems to me it would be a natural fall to contract locally, take care of it so you don't have to travel halfway across the western united states and back again. >> the i think that's more appropriate for someone else on the panel. >> okay.

anyone else want to take a shot at it? if not, it's yours, paul. ma'am? ma'am? >> um, all i can say on that because i'm not an expert on that aspect is that i know that there's some fee-based care in vha. >> yeah. >> i do not know how they decide when it goes to fee-based care or not. >> okay. yeah. >> so -- >> okay. i'm shooting it back to you, paul. >> so when you're in the fight and you need ammo, you put your hand back, and you get ammo. you've heard from mrs. nicely, they need immediate care. >> right. >> and i think whether or not it's a contract is like d.c. talk to folks in the field. >> right. >> they want to know who can i call right now to help me. >> right. >> and i think whatever it takes to deliver at that point of impact is what we need to come up with. >> right. that's my perspective, too, i think having people who need knee or hip replacement on a list for two years, it's not a

good way to run a ship. and i understand the problem with recruitment in rural america. it's in the private sector and the public sector both, so it's really important. my time has run out, long past. i will thank you all for your testimony and appreciate your perspectives. >> thank you very much. senator izaakson. >> i want to compliment crystal on her courage and bravery to be here, and i want to take the presumptive position of recommending to the chairman and the ranking member that her testimony be mailed to every member of the united states senate as required reading because i think it's a story that needs to be told over and over. sometimes we get so busy doing things like we're doing right now which is running around in circles, we don't really take into consideration those that are meeting tremendous challenges in life because of what they to do. you're a real hero to me, and i hope the chair will do that so that every member of the senate gets an opportunity to read -- >> i would hope that all of america hears.

>> absolutely. and, paul, i appreciate you being a very articulate spokesman on behalf of our iraqi and afghanistan veterans. they're going to need it over the years. there are a loot of 'em, and the -- lot of 'em and the challenges, just like crystal described, are greater. there are a lot of people surviving battlefield injuries that didn't before that require a tremendous amount of help and support. so i appreciate what you're doing. crystal, on the non-medical attendant, when you were answering senator brown, you said that the va provides one for up to six months? i thought i heard you say? >> i think it's actually military compensation because the va don't pick you up until after you're, the service member has retired. so, um, it's military compensation, and it's up to six months, i think that's the requirement from my understanding. when i first initially applied for the nonmedical attendant, they did it for a year, and then i was informed that it could

only be six months. so when i -- and then i was informed before applying again that i was, i didn't rate it because i was transferred with todd by record book. >> so you're compensated by the va as a nonmedical attendant during that period of time? >> not yet. no, sir. >> what i was trying to get at, scott's question was right on point with me, why in the world you'd have to continue to reapply to be a nonmedical attendant over and over again. >> it is frustrating, i guess. if service member does need the assistance and the family is here to care or a friend or whatever the case may be, i don't know, i just know that they do require you to reapply. >> i know walter reed is being closed in the next 30 days if i'm not mistaken. have you had any consultation with the new move to bethesda?

i guess todd will be moving to bethesda, is that right? is. >> actually, due to senator murray's kicking in the butt -- >> she's good at that, by the way. >> we actually have a date which he's going to retire. so we actually will not be, have to do the move. but they are, um, they just recently had a town hall meeting for service members to come to so that way they could explain the move and ask questions if need be. >> ms. st. james, thank you very much again, crystal. ms. st. james, i know you're in the physical evaluation which means the bricks and mortar, that type of thing. do you, do you feel like the va is making adequate plans in terms of that? and going to senator tester's statement about contract services particularly in states like montana and take south georgia where we have 63 counties where we don't have a

physician, private or va for that matter. do you think the va is making adequate plans to deal with what's going to be a higher volume of services because of the veterans of iraq and afghanistan in terms of the fiscal plan? >> we looked at their planning process both on the part of bricks and mortar, as you mentioned, as well as looking at their enrollee health care projection model, and on the physical infrastructure side the new planning process that they have which is called s.k.i.p., we haven't had time to really evaluate that to know whether or not it is taking into account what needs to be done. it does take into account that overall plan what needs to be done on the health care side for those services, but quite honestly, the s.k.i.p. process is new. we haven't had time to evaluate it. so i can only say that they have, va appears to have progressed from its earlier days, but the s.k.i.p. process

was just used to inform the 2012 budget, so we don't know how effective it's going to be. >> thank you. thank you, madam chairman. >> thank you. senator boozman. >> thank you, madam chair. and again, crystal, we really do appreciate, appreciate all of y'all's testimony. you've done a good job, and it's been informative. you represent your family and your husband very, very well, and more importantly i think all of the other families, you know, that are in the same situation. so give yourself a pat on the back. like i say, you've done very, very well and very helpful. here so much comes from the top down, and it's so important, and i just appreciate you, madam chair, you know, having her here in the sense that we don't dwell from the bottom up in the sense, you know, the people that are out, actually out there fighting the battle like you're doing, you know, on a daily basis. and it really is very helpful. paul, i think the comment you

made about the faith-based communities or the faith-based interaction in the communities and not just faith-based, but just all of, you know, the nonprofits, the charitable organizations are trying to do a good job. one of the problems that we have, we see all of these deployments from our guard units. and they unlike, you know, going off with a regular unit and then coming back, you're still with your buddies, you know, life goes on. but just all of a sudden to be thrown back -- and many times myself representing a southern state, many times going back, and i think that's probably true throughout the country, going back to small communities where there's not a lot of resources, you know, very limited with the va. and then just the nature of the beast of how they're separated, it really is real important. so we'd like to work with you to strengthen, you know, your ideas on how we strengthen those relationships and encourage that to flourish.

do you, could you comment about that for a second? is. >> the yes, sir. i just, you know, i think it's about wrapping the communities around these veterans when they come home. and what's so unprecedented is the small percentage of people who are serving relative to the overall population. so if we can find creative ways to galvanize around those veterans, it will be a worthy investment. i think what i see in the local communities and rural areas especially is a patchwork of services. if someone calls me from rural montana and says my husband's suicidal, the services available to them are going to be dramatically different than kansas or florida or somewhere else. so our team has a difficult time of being able to deliver or even connect them with reliable services was it's so patchwork nationally. and i really firmly believe there hasn't been a significant investment nationwide in those community groups of all kinds. and the comparison we've started to draw recently is the veteran space right now is kind of like aids 25 or 30 years ago, 25

years ago when you didn't have existing infrastructures. there's no massive philanthropic investment, no corporate investment. a lot of the nonprofits only started seven, eight years ago, so we're really in the early stages of creating an entire national network around a totally new set of issues. whether it's multiple amputee, amputations or traumatic brain injury or women's issues. a lot of the stuff is new, and there's not a system in place nationwide to tackle it. so i think we've really got to issue a national call over and over again on some of the issues that senator tester talked about earlier. the fact that we still don't have enough qualified mental health care workers is ridiculous. i've been coming here every year and talking about this. if president stood up tomorrow and said if you want to serve your country, go work at the va, at the dod, and we're going to support and train you, that's a great way for people to support their country, and i think they would step up. we've got to make those calls